ManagingPain:
KeyPointsSpecialPainManagementCommission19September2016
DanielB.Carr,M.D.
ProfessorandDirector,PainResearch,EducationPolicy(“PREP”)Program
TuftsUniversitySchoolofMedicine
Today’sTalk
Updateonpainpharmacotherapyandtheoptimalsequencefornondruganddrugtreatments(includingopioids)
Citetools,instrumentstoincreasecomfortlevelandefficiency,raisesatisfactionscores,decreaserisk
Presentevidenceforchronicpainasahighlyprevalentdiseaseentityperse
Whentorefertoapainspecialist
ChronicPainTherapy:Goals
Decreasepainintensity(restingandwithactivity):NOTEonlyonedimension
ImproveotherdimensionsofHRQOL
Rehabilitate/restore(PT,OT,psychology)
Vocationalcounseling/retraining,re-entry
“Bigpain,smalllife”to“smallpain,biglife”
Curesometimes,treatoften,carealways
SLOTMACHINE
PERSONPAINPRODUCT
PAINHISTORY:DRILLINGDOWN
Onset
Site(diagram)
Character(NPP)
Intensity(resting,movement,now,worst)
Effects(sleep,work,function,family,mood)
Meaning(expectations,beliefs,knowledge,culture)
CAMuse(acupuncture,hypnosis,etc)
INITIAL+F/UEVALUATIONS
Documenttherapies,PGE,targetedphysicalexam
Substanceabuserisk(e.g.,alcohol)
–ForopioidRxconsiderSOAPPinitially,thenCOMM
Trackoutcomes
–Physicalfunction(MPI,BPIinterferencescale)
–Emotionalfunctioning(Beckdepression,POMS)
–Overallimprovement(PGEchange)
–Painintensity(0-10VRSBUTfunctionoftenbetterindex)
Labtesting--UDT
Assessneedtoadjusttreatmentplanorrefer
PAIN101:BASICMENU
Non-drugmethods(inclIntegrative,CAM)
–Physicalmeasures(heat,cold,splint)
–Cognitive-behavioral(cf.PTSD)
–ProvenefficacybymultipleRCTs,M-As
Drug
–NSAIDs(notallalike;ceilingforbenefit,notrisk;Solomonetal,ArchIntMed2010)
–Opioids(varieddrugs,dosageforms,people)
–Localanesthetics(topicalorinjected)
–Adjuvants(boosteffects,Rxside-effects)
NSAIDs:OVERVIEW
Original,mostwidelyusedsyntheticanalgesics
Classifiedbychemicalstructure
First-linepaintherapyinacute,chronicandcancer-relatedpain
Componentofmultimodalanalgesia
Considerablemorbidity,mortalityworldwide(GI,renal,CV,platelet)2015FDAalert
TraditionalNSAIDshavelimitedselectivelyforCOXisoforms;COX-2selectiveagents=“coxibs”
Low-doseASAusefulforMI,stroke,colonCaprophylaxis
COXIBS:CVRISKS
Mukherjee(2001)comparedannualizedratesofMIfromCLASSandVIGORwithpooled placebogroup(N=23,000)resultsfrom4ASApreventiontrials.
AnnualizedMIrates0.52%fromplacebogroup,0.80%forCelecoxib(P0.02),0.74%forRofecoxib(P=0.04)
2005FDA,MHRAmemoscautionedagainstlong-(orforparecoxib,short-)termuseofNSAIDsduetoCVrisks;rofecoxibandvaldecoxibwithdrawn,parecoxibnon-approved
Celecoxibremains(n.b.meloxicam,diclofenac)
ContinuumofRisk:COX-1vsCOX-2
CVRiskStroke
ClotMIBP
EDGE
VIGOR
CLASS
GIRisk
UlcerGIbleed
COX-2COX-1
1111
PARACELSUS(1493-1541)
Allsubstancesarepoisons;thereisnonewhichisnotapoison.Therightdosedifferentiatesapoisonfromaremedy.
ADJUVANTMEDICATION
Adrugusedtoenhanceeffectivenessofa10analgesic–typicallyanopioid--orreducesideeffect(s)ofa10analgesic
AlthoughNSAIDs,COXIBSandLAsfitthisdefinition,byconventiontheyaregenerallyexcluded
Inpractice,referstoAEDs,TCAs,etcespeciallywhenappliedtotreatneuropathicpain
Antidepressants
–TCA(e.g.,amitriptyline,imipramine…)SSRI(e.g.,fluoxetine),SNRI(e.g.,duloxetine)
–30%ofpatientswithneuropathicpaingivenantidepressantswillobtain50%painrelief
–30%willhaveminorAEs
–4%willceasetreatmentduetomajorAEs
–Limitedliterature,butnocleardifferenceinefficacyacrossconditionsordrugs
Anticonvulsants
–gabapentin,pregabalin,clonazepam,
–valproate,lamotrigine,topiramide,zonisamide,oxcarbazepine,levotireacetam,[carbamazepine(TGN),phenytoin]
–NNT=1.6foreffectiveness,2.4forAEs,39.3fordrug-relateddropoutinRCTs(exc.gabapentin)
–Demant(Pain,2014):phenotypingirritablevs
nonirritablenociceptortoguideRx?
AEDsBetterfor“Irritable
Nociceptor”PeripheralNPP?
Demantetal,Pain2014:Oxcarbazepine[Trileptal]
ADJUVANTS(3)
Na+(mexiletine)orCa++blockers
NMDAantagonists(ketamine,dextromethorphan,amantadine…N.B.alsodextropropoxyphene,methadone)
Alpha-2agonists(clonidine,tizanidine)
GABAagonist(baclofen)
Phenothiazines,thioxanthines
Butyrophenones(haloperidol)
+Topicalagents(lidocaine,capsaicin)
MARCUSAURELIUS(121-180)
Whenunbearable,paindestroysus…Recollectthis,too,thatmanyofoureverydaydiscomfortsarereallypainindisguise,such asdrowsinessorwantofappetite.
Meditations(c.160)
INDIVIDUALVARIABILITY
Genetic:preclinical,clinical
Gender
Priorsensitization(oftenpresentonHx)
Psychosocial(litigation/compensation,job/familysatisfaction,spousalsolicitousness,premorbiddepression,abuse)
Clinician-patientinteraction(?enabling,medicalizingasomatoformdisorder) 19
OpioidGuidelines:SharedElements(CDC 2013)
PEx,painHx,pastmedicalHx,family/socialHx
Urinedrugtesting,whenappropriate
Consideralltreatmentoptions,weighingbenefitsandrisksofopioidtherapy,andusingopioidswhenalternativetreatmentsareineffective
Startpatientsonlowesteffectivedose
Paintreatmentagreements
Document/monitorongoingpain,Rxprogress,PDMP
Usegreatervigilanceathighdoses
Usingsafeandeffectivemethodsfordiscontinuingopioids(e.g.,tapering,specialistreferra20ls)
“QualityOpioidPrescribing”
(BCBSofMA,2012)
Treatmentplanincludingacleardiagnosis,explciitgoals,andexplorationofothertreatmentoptions
Informedconsentandformalassessmentofaddictionrisk(excludescancer,end-of-life)
WrittenagreementbetweenprescriberandpatientaddressingissuesofRxmanagement,diversionanduseofothersubstances
AccountableRxgroup,useof1pharmacy/chain
Urinedrugtesting+specifics(e.g.,2x15dayRx)
5StepsofOpioidPrescribing
AssesspainAbuserisk(RxAgreement)
BelieveButverify(UDT)
ChooseperContext
DeliverRxDeliberatelyandcarefully(PMP)
Enable,Empower:focusonfunction
AdaptedfromJacox,Carr,Payneetal,1994
Pain:aPublicHealthIssue
IOM,WHOhavedeclaredpainapublichealthissue:
•Highprevalence,burden
•Amenabletoprevention(e.g.,acute-to-chronictransition)
•Population-basedphenomenonwithclearrelationtoSES
•Humanrightsdimensionincludinginequitiesin
access23
DyadicvsSupradyadic
HealthcareModels
SmithandChristakis,AnnRevSociology(2008)
24
PainvsRejection(Wager2013)
“Comparisonsofrejecterversusfriendandpainversuswarmthyieldedsimilarlevelsofself-reportednegativeaffect,andoverlappingportionsofmanyregionsrelatedtopainintensitywereactivated(bilateralanteriorinsula,medialthalamus,secondarysomatosensorycortex,anddorsalposteriorinsula)2.”5
ThePerfectAnalgesic?
PAIN202:PAINASADISEASE
(SiddallandCousins,2004)
Injurytriggersacascadeofresponses
PNS,CNSpromptlyadapt,reorganize,remember
“Programmedinstability”linkspain,memory
Acuteandchronicpain=continuum
Increasingdocumentationofchronicneuropathicpainaftersurgery(NNH2-7)
UnclearwhyNNHisn’t=1
SPECIALISTREFERRAL?
“Buildanetworkofclinicalexpertstowhomyoucanturn”[Fishman]
“Knowyourlimitsandreferearly”
“Bespecificinyourrequestsandinturnexpectcommunicationback”
Why?clarifydiagnosis;specializedorinvasiveRx;titratingmultimodalregimen(~DM);failuretoimproveHRQOL(notPI)
Nondrug/non-opioidRxwheneverpossible
Validate,titratechronicopioidRx